APPLICATION FOR SUBSIDIZED HOUSING

Elgin Branch 110 Centre Street St. Thomas, Ontario N5R 2Z9 Tel (519) 633-1781 Fax (519) 631-8273 Email: admin@cmhaelgin.ca Website: www.cmhaelgin.ca APPLICATION FOR SUBSIDIZED HOUSING If you need help filling out this application, please contact the Housing Case Manager at 519-633-1781 ext. 136. Eligibility To be eligible for our housing program, you must meet all of the following criteria: You must be 16 years of age or older. You must be diagnosed with a Serious Mental Illness. You must be a Canadian Citizen, Landed Immigrant (Permanent Resident), or have Refugee Claimant Status with no removal / deportation order in place. If you own any property (house, condominium, cottage, etc.) which you could live in all year, you must sell or transfer the property no later than 180 days (about 6 months) after you move into the apartment we rent to you. You must not owe any rent arrears or damage costs to another social housing provider, but you might still be eligible if you enter into a payment plan with that social housing provider. If you need help setting up a payment plan, please contact CMHA s Housing Case Manager at 519-633-1781 ext. 136. Providing false information for the purpose of obtaining subsidized housing may make you ineligible for subsidized housing. Instructions If your application is not complete, there will be a delay in determining your eligibility for subsidized housing. Please print all information in ink. It is your responsibility to let us know if your housing circumstances change. We need to know about changes in your permanent resident or refugee status, income, family composition, housing circumstances, and contact information. If we cannot contact you at the telephone number, address, or e-mail address that you have given us in this form, your application might be cancelled. Before submitting your application, please use the following checklist to make sure that your application is complete: Yes, I have completed all sections and pages of the application. Yes, I have read Section I and understand that I will need to provide all required documentation before a rental unit can be made available to me. Note: You do not need to include this documentation now, but it will be required before you occupy a rental unit. Yes, I have signed Section J Declaration and Consent. Once completed, your application may be dropped off, mailed, or faxed to: Attn: Housing Case Manager Canadian Mental Health Association, Elgin Branch 110 Centre Street St. Thomas, Ontario N5R 2Z9 Fax: 519-631-8273 PLEASE INCLUDE THIS PAGE WITH YOUR APPLICATION Applicant Surname Date Received

SECTION A Applicant Information Last Name Apt #/P.O. Box First Name and Initial Address City Province Postal Code Phone Number Date of Birth Email Address (optional) Sex: Male Female Citizenship: Canadian Citizen Permanent Resident ( landed immigrant ) Refugee Claimant Deportation Order Present Accommodations: Own / Co-Own Rented Unit Subsidized Housing or Co-Op Shelter Group or Care Home Living on the street Couch Surfing Jail Hospital Hotel or Motel Living with Family or Friends If you are in hospital or are incarcerated, please provide your discharge / release date, if known (dd/mm/yy): If you live in subsidized housing or a co-op, why do you want to live in CMHA housing? Amount you pay each month in rent Average amount you pay each month for gas, water, and electricity SECTION B - Other Members of the Household 1. 2. 3. 4. 5. Last Name First Name Date of Birth Sex (M / F) Student (Y / N) Relationship to Applicant SECTION C - Subsidized or Rent-Geared-to-Income Rental History Have you previously resided in subsidized or rent-geared-to-income housing? Yes No If Yes, please list the names of the housing provider(s) and dates: Housing Provider Start Date End Date Have you or a member of your household ever been charged and convicted of an offense because you gave false information about your income or assets to a housing provider? Yes No Do you owe rent or damage arrears to any social housing provider? Yes No If Yes, do you have a repayment plan in place? Yes No SECTION D Miscellaneous Information Do you own a vehicle? Yes No Are you a member of the Canadian Mental Health Association, Elgin Branch? Yes No If No, have you started the Intake process? Yes No If Yes, do you receive Case Management Services? Name of Case Manager: Yes No I am interested in obtaining housing in the following areas of Elgin County (check all that apply): St. Thomas Aylmer Dutton West Lorne Other: Page 1 of 4

SECTION E - Declaration of Household Income & Assets Below, please declare monthly household income and the value of all assets for all members of the household. You do not need to provide any documentation proving your income or assets now, but you will need to provide documentation before you can occupy a rental unit. Some examples of documentation we accept are listed below. Only one piece of documentation is typically needed for each source of income reported: Your most recent Income Tax Notice of Assessment Cheque stub(s) from work ODSP Statement of Assistance Ontario Works statement Pension and insurance income cheque stubs Bank book(s) recent transactions Interest or investment income statement(s) Statement of Interest / Capital Gains Income Source Applicant Other Member Other Member Ontario Disability Support Program (ODSP) Ontario Works (OW) Employment Income from Self-Employment (income after deducting allowable business expenses) Employment Insurance (EI) Canadian Pension Plan (CPP) Old Age Security (OAS) Other Pension(s) Injury or Disability Compensation (i.e. W.S.I.B., Long- Term Disability) Child Support Payments / Alimony Annuity (RIF) Other Income (specify: ) TOTAL INCOME FROM ALL SOURCES Asset Type Applicant Other Member Other Member Investments (GICs, mutual funds, bank account balance exceeding $2000, etc.) Property / Real Estate Other Asset(s) (specify: ) TOTAL VALUE OF ASSET(S) If you own real estate, are you the only owner? Yes No If you own real estate, could someone live in it year-round? Yes No Do you pay child support? if Yes, what amount each month? Yes No SECTION F Special Accommodations Can you climb stairs? Yes No Do you need a modified unit because of a physical disability? If Yes, please describe the type of unit you need: Yes No Do you need an extra bedroom because You have regular overnight access with a child who does not live with you all the time? Yes No A member of your household is pregnant? Yes No You need to store medical equipment because of a disability or medical condition? Yes No You have a live-in personal care provider who is not a family member? Yes No Page 2 of 4

SECTION G - Priority Considerations Family Violence (please choose the statement which best describes your circumstances) I currently do not live with someone who abuses me or my child(ren). I currently live with someone who is abusing me or my child(ren). If checked, please indicate a telephone number at which you can be safely reached: I used to live with someone who abused me or my child(ren), but I am now living in a shelter. I used to live with someone who abused me or my child(ren), but I am now living with friends or family. Someone who used to abuse me or my child(ren) knows where I live, and I feel that my safety and/or the safety of my child(ren) is threatened. Children (please choose the statement which best describes your circumstances) In this section, dependent child means a person under 18 years of age, or a person of any age if that person has a developmental or intellectual disability. I have no dependent children living with me. I have one or more dependent children who live with me. I have one or more dependent children who are not in my care. Provide any additional information you feel should be considered in assessing your priority for housing: SECTION H - Agents An agent is a person whom you allow to make certain decisions about your housing. An agent cannot sign a lease for you, but he or she can set up appointments for us to meet with you, and we can exchange information about you and your housing circumstances with your agent. An agent might be a case manager, family member, trustee, or friend. You are not required to have an agent but, if you want to allow someone to act as your agent, please list his or her name below, and also list his or her relationship to you (e.g. case manager, friend, mother, brother, trustee, etc.). Name Agents Relationship to Applicant / Household SECTION I Verification Documents Some documentation is required to verify the statements you have made in this application. You do not need to provide these documents now, but you will need to provide the following documents before housing can be made available to you: (a) a photocopy of a document verifying the citizenship information you have provided in Section A (e.g. birth certificate, health card, passport, Record of Landing or other immigration document); (b) photocopies of documents verifying income and assets for all household members (for a full list of acceptable documents, please see Section E); (c) a photocopy of your most recent property tax assessment if you own real estate. Page 3 of 4

SECTION J Declaration and Consent Preamble Below, the terms we, us, and our mean the Canadian Mental Health Association, Elgin Branch. The terms you and your mean any person who is signing below. Privacy We respect your privacy. We will use the information you have given us in this application only to decide if you are eligible for our subsidized housing program, and also to decide how quickly you need housing. We will only share your information with other people or organizations if you tell us that we can share it, unless we are required to share your information because a law says we have to share it. If you have questions about your information, how we store it, or how we might share it, please call the Housing Case Manager at 519-633-1781 x136 or our Privacy Officer at 519-633-1781 x124. Discrimination When we are deciding whether you are eligible for housing, it does not matter to us whether you are married, or whether you have children. We will never deny you housing because of the colour of your skin, where you were born, or what groups you belong to. We will also never deny you housing if you have a disability or because of your age, sex, gender, or sexual orientation. The information we have asked you to give us in this application is requested because there are laws that say we need that information or because it helps us match you and your household to housing that meets your needs. If you have questions about how your information will be used, please call the Housing Case Manager at 519-633-1781 x136. Wait List If you are found eligible for our subsidized housing program, you will be placed on a wait list, but we can remove you from the wait list if: (a) we discover that you have given us false information, either in this application or in information you give us in the future; (b) you are no longer eligible for the program; (c) we cannot get in touch with you using the contact information you have given us; (d) you do not give us information about your current housing or income when we ask for it; (e) you accept subsidized housing through another housing provider. We offer housing first to applicants who need it the most. It is your responsibility to tell us if there are changes in your housing, finances, or family structure and you feel that those changes might change your priority for housing. Consent You agree that we can contact housing providers, organizations which manage housing wait lists, and benefits providers or employers to confirm that the information you have given us is true. You also agree that we can give those organizations any information about you that they need to find and access any record they might have on file for you. You agree that we can share information about you with any person you have listed in Section H of this application ( Agents ), and that your agents can share information about you with us. You also agree to allow any of your Agents to act on your behalf with respect to your housing, including scheduling meetings with the Housing Case Manager. If you do not want one of your Agents to continue to have authority to act on your behalf, or you do not want us to exchange information with one of your Agents, this is called revoking consent. If you want to revoke consent, please tell us and we will no longer communicate with that person. Revoking consent will not affect your eligibility for housing. Declaration By signing below, you confirm that you have read and agree with the contents of this section (Section J), and you declare that the information you have given us in this application form and any additional documentation you give us is accurate and complete to the best of your knowledge. Applicant s Signature: Applicant s Signature Date INITIALS Name of CMHA Employee OR I am an employee of the Canadian Mental Health Association, Elgin Branch and I declare that, on the date written above, I explained the contents of this section to the applicant and the applicant verbally expressed understanding and consented to the statements contained therein. Page 4 of 4